CMS and AMA payment and coding updates, effective July, 1 2020
Panacea has summarized the Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA) payment and coding updates, effective July 2020 (with some retroactive changes). Please review the updates for possible implementation in your hospital chargemaster and/or review by applicable department, coding and billing staff.
Note: There are many updates for July 1, 2020 and we have summarized several of the significant updates below. Readers will need to go to the CMS Transmittal 10166 for a full review of the OPPS updates at the link provided here https://www.cms.gov/files/document/r10166cp.pdf. For July updates to the I/OCE click the following link https://www.cms.gov/files/document/r10165cp.pdf.
COVID-19 PHE: Virtual Services Update
CMS has further clarified the use of certain Virtual Services CPT and HCPCS Codes along with payment status. The payment status indicator is changed to “A” (Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS). These changes are retroactive to March 1, 2020. Below is a summary of who in the facility (and/or practitioner) may provide these services and can be billed accordingly as the professional service (1500) and/or UB04 (1450) for the setting in which the service is provided. The virtual outpatient service during the PHE may be reported when the practitioner or clinician is not in the same location as the patient. Patient may be at home or at another temporary location. Revenue integrity and clinical staff will need to ensure understanding of proper reporting of these codes.
| HCPCS Code |
Long Description |
SI |
Practitioner or Clinician |
| G2010 | Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment | A | Physicians and mid-level providers |
| G2011 | Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion | A | Physicians and mid-level providers |
| 98966 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion | A | Clinicians (e.g., mid-level provider, therapists, counselors, psychologists) |
| 98967 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion | A | Clinicians (e.g., mid-level provider, therapists, counselors, psychologists) |
| 98968 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion | A | Clinicians (e.g., mid-level provider, therapists, counselors, psychologists) |
| G2061 | Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes | A | Rehabilitation therapists, behavioral health counselors |
| G2062 | Qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes | A | Rehabilitation therapists, behavioral health counselors |
| G2063 | Qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes | A | Rehabilitation therapists, behavioral health counselors |
Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes for C9754 and C9755
CMS is deleting temporary HCPCS codes C9754 and C9755 and replacing them with G2170 and G2171 respectively. This change is effective July 1, 2020 and with this change the procedure code descriptors have also been revised. Code G2170 will be reported when the Ellipsys System is used for an AVF procedure using thermal resistance energy with redirection of blood flow and code G2171 will be reported when the WavelinQ System is used for AVF procedure performed with magnetic-guided arterial and venous catheters and radiofrequency energy with flow-directing procedures. The new HCPCS codes will continue to be assigned to J1 status indicator under the OPPS. These new HCPCS codes should be reviewed by coding staff.
| HCPCS Code | Long Descriptor | Add Date | Term Date | Replacement Code |
| C9754 | Creation of arteriovenous fistula, percutaneous; direct, any site, including all imaging and radiologic supervision and interpretation, when performed and secondary procedures to redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization, when performed) | 1/1/2019 | 6/30/2020 | G2170 |
| G2170 | Percutaneous arteriovenous fistula creation (AVF), direct, any site, by tissue approximation using thermal resistance energy, and secondary procedures to redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization) when performed, and includes all imaging and radiologic guidance, supervision and interpretation, when performed | 7/1/2020 | N/A | N/A |
| C9755 | Creation of arteriovenous fistula, percutaneous using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil embolization with radiologic supervision and interpretation, when performed) and fistulogram(s), angiography, venography, and/or ultrasound, with radiologic supervision and interpretation, when performed | 1/1/2019 | 6/30/2020 | G2171 |
| G2171 | Percutaneous arteriovenous fistula creation (AVF), direct, any site, using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil embolization with radiologic supervision and interpretation, wen performed) and fistulogram(s), angiography, enography, and/or ultrasound, with radiologic supervision and interpretation, when performed | 7/1/2020 | N/A | N/A |
New Skin Substitutes/Biologicals
CMS has created 13 new skin substitute HCPCS codes effective for use July 1, 2020. We remind readers that skin substitutes are divided into two groups by CMS: 1) high cost skin substitute product that is reported in addition to applicable CPT codes 15271-15278 and 2) low cost skin substitute product that is reported in addition to applicable HCPCS codes C5271-C5278. Additionally, nine new wound biological HCPCS codes have been created. These HCPCS are not assigned to one of the skin substitute groups because they come in injectable or powder form for use with surgical procedures. These biologicals are placed in the surgical wound bed to promote healing at the surgically created wound site. These new wound biological HCPCS codes are present in the table below with “N/A” in the Low/High Cost Skin Substitute column. Finally, note that new HCPCS code C1849 description “skin substitute, synthetic” describes products formed from synthesized materials (e.g., silicone). A couple examples of these products are Biobrane™ and TransCyte™. Revenue integrity and/or chargemaster coordinators will need to review the hospital chargemaster to determine if there are current chargemaster service lines for these synthetic skin products and ensure the HCPCS code is updated accordingly.
| HCPCS Code | CY 2020 Short Descriptor | CY 2020 SI | Low/High Cost Skin Substitute |
| C1849 | Skin substitute, synthetic | N | High |
| Q4227 | Amniocore per sq cm | N | Low |
| Q4228 | Bionextpatch, per sq cm | N | Low |
| Q4229 | Cogenex amnio memb per sq cm | N | Low |
| Q4230 | Cogenex flowable amnion, per 0.5 cc | N | N/A |
| Q4231 | Corplex p, per cc | N | N/A |
| Q4232 | Corplex, per sq cm | N | Low |
| Q4233 | Surfactor or nudyn, per 0.5 cc | N | N/A |
| Q4234 | Xcellerate, per sq cm | N | Low |
| Q4235 | Amniorepair or altiply sq cm | N | Low |
| Q4236 | Carepatch per sq cm | N | Low |
| Q4237 | Cryo-cord, per sq cm | N | Low |
| Q4238 | Derm-maxx, per sq cm | N | Low |
| Q4239 | Amnio-maxx or lite per sq cm | N | Low |
| Q4240 | Corecyte, for topical use only, per 0.5 cc | N | N/A |
| Q4241 | Polycyte, for topical use only, per 0.5 cc | N | N/A |
| Q4242 | Amniocyte plus, per 0.5 cc | N | N/A |
| Q4244 | Procenta, per 200 mg | N | N/A |
| Q4245 | Amniotext, per cc | N | N/A |
| Q4246 | Coretext or protext, per cc | N | N/A |
| Q4247 | Amniotext patch, per sq cm | N | Low |
| Q4248 | Dermacyte Amn mem allo sq cm | N | Low |
New Surgical Procedures
CMS has created two new temporary surgical procedure HCPCS codes (C9759 and C9760). Both codes are effective for use July 1, 2020. Code C9759 is reported for intraoperative transcatheter microinfusion(s) therapy and code C9760 is reported when non-blind intraatrial shunt implantation is performed in an approved investigational device exemption (IDE) study. The coding staff will want to review the descriptions and understand how these procedures will be documented for accurate reporting.
| HCPCS Code | Short Descriptor | Long Descriptor | APC | SI |
| C9759 | Transcath intraop microinf | Transcatheter intraoperative blood vessel microinfusion(s) (e.g., intraluminal, vascular wall and/or perivascular) therapy, any vessel, including radiological supervision and interpretation, when performed | N/A | N |
| C9760 | Non-blind interatrial shunt | Non-randomized, non-blinded procedure for NYHA Class II, III, IV heart failure; transcatheter implantation of interatrial shunt or placebo control, including right and left heart catheterization, transeptal puncture, trans-esophageal echocardiography (TEE)/intracardiac echocardiography (ICE), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (IDE) study | 1591 | T |
Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI)
CMS has created temporary HCPCS codes C9762 and C9763 to report strain imaging and stress imaging associated with strain-encoded cardiac MRI which is a new study for fast estimation of left ventricular function. This study provides real-time acquisition of myocardial performance in a single heartbeat. See table below for assigned status indicator and APC. Based on the APC assigned the national estimated payment is $481.58. These new codes will need to be reviewed with applicable staff and set up for use in the hospital chargemaster as applicable.
| HCPCS Code | Long Descriptor | OPPS SI | OPPS APC |
| C9762 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging | Q3 | 5524 |
| C9763 | Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging | Q3 | 5524 |
Peripheral Intravascular Lithotripsy
CMS has created temporary HCPCS codes C9764, C9765, C9766 and C9767 to describe technology associate with peripheral intravascular lithotripsy. Shockwave Medical device for coronary intravascular lithotripsy received FDA Breakthrough Device Designation; therefore, CMS is implementing new codes to allow Medicare beneficiaries access to this new technology. The Shockwave IVL catheter is designed to fracture calcium in coronary arteries using sonic pressure waves which facilitates delivery of stents. Coders and applicable staff will need to be aware of use of this technology in the hospital and ensure staff understanding of the code descriptors to select the most applicable code for the procedure performed.
| HCPCS Code | Long Descriptor | OPPS SI | OPPS APC |
| C9764 | Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, includes angioplasty within the same vessel (s), when performed | J1 | 5192 |
| C9765 | Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed | J1 | 5193 |
| C9766 | Revascularization, endovascular, open or percutaneous, any vessel (s); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel (s), when performed | J1 | 5193 |
| C9767 | Revascularization, endovascular, open or percutaneous, any vessel (s); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel (s), when performed | J1 | 5194 |
| Refer to the July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) change request (CR) document for payment and other information related to these HCPCS code(s). https://www.cms.gov/files/document/r10166cp.pdf |
AMA New Category III Codes
The American Medical Association (AMA) created new CPT Category III codes for 2020. There are 25 new Category III codes effective for use effective July 1, 2020. Due to the number of new codes, we advise readers to view the complete list of new codes for applicable OPPS status indicator and APC assignment in the CMS Transmittal 10166 and go to the AMA website to view the medium and short descriptors and applicable code parentheticals for use of the new codes. Coders and applicable staff will need to review this list of codes and update the chargemaster with service lines needed to code and bill for these services.
Refer to the AMA website for further information regarding the Category III codes https://www.ama-assn.org/practice-management/cpt/category-iii-codes
AMA Changes to Proprietary Laboratory Analyses (PLA) Codes
The American Medical Association (AMA) is deleting five PLA codes and has created 30 new PLA codes effective for use effective July 1, 2020. Due to the number of code changes, we advise readers to view the completed list of new codes for applicable OPPS status indicator in the CMS Transmittal 10166 and go to the AMA website to view the proprietary clinical laboratory/manufacturer name and short descriptors. This information will need to be reviewed by the laboratory team and applicable staff for implementation of updates to the laboratory chargemaster.
Refer to the AMA website for further information regarding the Proprietary Laboratory codes https://www.ama-assn.org/practice-management/cpt/cpt-pla-codes
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